The effect of pre-Affordable Care Act (ACA) Medicaid eligibility expansion in New York State on access to specialty surgical care

Poverty and Its Impact on Surgical Care

In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review

OBJECTIVE

Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment.

DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed.

SETTING

Not applicable.

PATIENTS

Patients with craniosynostosis.

INTERVENTIONS

Standard surgical intervention for craniosynostosis.

RESULTS

Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications.

CONCLUSIONS

Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

Surgical Care for Racial and Ethnic Minorities and Interventions to Address Inequities: A Narrative Review

OBJECTIVE

Racial and ethnic inequities in surgical care in the United States are well documented. Less is understood about evidence-based interventions that improve surgical care and reduce or eliminate inequities. In this review, we discuss effective patient, surgeon, community, health care system, policy, and multi-level interventions to reduce inequities and identifying gaps in intervention-based research.

BACKGROUND

Evidenced-based interventions to reduce racial and ethnic inequities in surgical care are key to achieving surgical equity. Surgeons, surgical trainees, researchers, and policy makers should be aware of the evidence-based interventions known to reduce racial and ethnic disparities in surgical care for prioritization of resource allocation and implementation. Future research is needed to assess interventions effectiveness in the reduction of disparities and patient-reported measures.

METHODS

We searched PubMed database for English-language studies published from January 2012 through June 2022 to assess interventions to reduce or eliminate racial and ethnic disparities in surgical care. A narrative review of existing literature was performed identifying interventions that have been associated with reduction in racial and ethnic disparities in surgical care.

RESULTS AND CONCLUSIONS

Achieving surgical equity will require implementing evidenced-based interventions to improve quality for racial and ethnic minorities. Moving beyond description toward elimination of racial and ethnic inequities in surgical care will require prioritizing funding of intervention-based research, utilization of implementation science and community based-participatory research methodology, and principles of learning health systems.

Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF).

METHODS

Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes.

RESULTS

A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories.

CONCLUSIONS

In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.

Younger Individuals Increase Their Use of Nursing Homes Following ACA Medicaid Expansion

OBJECTIVES

This study examines the effect of Medicaid eligibility expansion under the Affordable Care Act (ACA) on the utilization of nursing home services by younger individuals and those covered by Medicaid.

DESIGN

Compared the age of nursing home residents, proportion of individuals covered by Medicaid, annual nursing home admissions in those younger than 65, and nursing home length of stay in states that expanded Medicaid eligibility through the ACA to states that did not. We used data from LTCFocus (nursing home level), the Minimum Data Set (individual level), and Medicaid expansion status from the Kaiser Family Foundation.

SETTING AND PARTICIPANTS

The study included 15,005,888 nursing home admissions, 2,446,950 of which were residents younger than 65, across 14,132 nursing homes between 2009 and 2016.

METHODS

A time-varying difference-in-difference model including state and year fixed effects with effect modification by pre-2014 nursing home occupancy.

RESULTS

Facilities in expansion states with a pre-ACA occupancy rate of more than 70% increased the fraction of residents younger than 65 by 2.74% to 6.32%, compared with similar facilities in nonexpansion states. Medicaid admissions varied, with an increase in year 2 after expansion compared with nonexpansion states. Among residents entering from an acute care hospital, the proportion younger than 65 increased in facilities with pre-2014 occupancy rates of more than 70%, compared with similar facilities in nonexpansion states, an increase of up to 6.51%. Median nursing home length of stay for individuals younger than 65 decreased relative to nonexpansion states across all occupancy categories, ranging from 1.68 to 6.06 days after Medicaid expansion.

CONCLUSIONS AND IMPLICATIONS

Medicaid expansion increased access to nursing home post-acute care for individuals younger than 65. It remains unclear if the benefit of post-acute care is the same among this group, or if the needs of younger individuals can be adequately met in this setting.

Evaluating the Impact of Patient Social Deprivation on the Level of Symptom Severity at Carpal Tunnel Syndrome Presentation

Background: There is a paucity of research examining the impact of social deprivation on the level of symptom severity at presentation, including in common hand conditions like carpal tunnel syndrome. We aimed to determine whether patient deprivation is associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores. Methods: Patients presenting to an academic hand clinic from December 2016 to December 2018 for a new patient visit for carpal tunnel syndrome completed PROMIS UE, PF, PI, and Depression Computer Adaptive Tests. Bivariate analyses were done to compare patient variables between the least and most deprived thirds, as measured by Area Deprivation Index (ADI), at the state (New York) and national levels. Multivariable linear regression was used to determine whether there was an association between social deprivation and PROMIS UE, PF, PI, and Depression scores. Results: All PROMIS domain scores were significantly worse in the most deprived cohort at the national level (P < .05) but not at the state level (P > .05). In multivariable regression at the national level, ADI values were associated with PROMIS UE (β = -0.06, P < .01) and PROMIS PI (β = .05, P < .01) but not PROMIS PF or PROMIS Depression. In multivariable regression at the state level, ADI values were associated with PROMIS UE (β = -0.79, P = .03) and PROMIS PI (β = 0.58, P < .05) but not PROMIS PF or PROMIS Depression. Conclusions: Higher levels of social deprivation are associated with worse PROMIS UE and PROMIS PI scores on both the state and national levels when initially seeking care for carpal tunnel syndrome.

Did Medicaid Expansion Mitigate Disparities in Post-mastectomy Reconstruction Rates?

Background

Patient and socioeconomic factors both contribute to disparities in post-mastectomy reconstruction (PMR) rates. We sought to explore PMR patterns across the US and to determine if PMR rates were associated with Medicaid expansion.

Methods

The NCDB was used to identify women who underwent PMR between 2004-2016. The data was stratified by race, state Medicaid expansion status, and region. A multivariate model was fit to determine the association between Medicaid expansion and receipt of PMR.

Results

In comparison to Caucasian women receiving PMR in Medicaid expansion states, African American (AA) women in Medicaid expansion states were less likely to receive PMR (OR .96 [.92-1.00] P < .001). Patients in the Northeast (NE) had better PMR rates vs any other region in the US, for both Caucasian and AA women (Caucasian NE ref, Caucasian-South .80 [.77-.83] vs AA NE 1.11 [1.04-1.19], AA-South (.60 [.58-.63], P < .001). Interestingly, AA patients residing in the NE had the highest receipt of PMR 1.11 (1.04-1.19), even higher than their Caucasian counterparts residing in the same region (ref). Rural AA women had the lowest rates of PMR vs rural Caucasian women (.40 [.28-.58] vs .79 [.73-.85], P < .001].

Discussion

Racial disparities in PMR rates persisted despite Medicaid expansion. When stratified by region, however, AA patients in the NE had higher rates of PMR than AA women in other regions. The largest disparities were seen in AA women in the rural US. Breast cancer disparities continue to be a complex problem that was not entirely mitigated by improved insurance coverage.

ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

BACKGROUND

Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients.

METHODS

State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states.

RESULTS

The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged.

CONCLUSION

Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

Utilization of High-Volume Hospitals for High-Risk Cancer Surgery in California Following Medicaid Expansion

INTRODUCTION

A primary goal of the recent state and federal health reform is to increase access to care through expanded insurance coverage. We sought to evaluate the effect of Medicaid expansion (ME) on four high-risk cancer operations in California.

METHODS

The California Office of Statewide Health Planning database was used to identify patients who underwent either lung, esophageal, pancreas, or rectal resection for cancer between 2012 and 2016. To include only patients eligible for Medicaid and not Medicare, patients > 65 years were excluded. Trends in insurance coverage rates and utilization of high-volume hospitals were evaluated relative to the pre-policy (2012-2013) versus the post-policy (2014-2016) period.

RESULTS

Overall 10,569 individuals (esophageal: 5.6%; lung: 38%; pancreas: 14.1%; rectal: 42.3%) underwent a cancer operation. Following ME, Medicaid coverage increased from 12.4 to 20.2% (p < 0.001). There were no differences in age, sex, and race of Medicare beneficiaries pre- versus post-policy implementation (all p > 0.05). Of note, following ME, there was an increase in probability of utilization of high-volume hospitals for lung (47.6% vs. 56.3%), rectal (74.0% vs. 77.7%), and pancreas (60.2% vs. 68.5%) (p < 0.05 for all) cancer operations. Overall probability of surgery at a high-volume center after expansion increased by 5.8% among Medicaid beneficiaries versus other patients in the same time period. ME was not associated, however, with improvement in clinical outcomes such as complications, in-hospital mortality, or readmission (all p > 0.05).

CONCLUSION

ME was associated with an increase in Medicaid coverage, which resulted in more beneficiaries undergoing cancer operations at high-volume hospitals. While ME was associated with increased access to care, peri-operative outcomes were comparable pre- versus post-ME implementation.

Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US

Importance

Contemporary data directly comparing experiences between individuals with public and private health insurance among the 5 major forms of coverage in the US are limited.

Objective

To compare individual experiences related to access to care, costs of care, and reported satisfaction with care among the 5 major forms of health insurance coverage in the US.

Design, Setting, and Participants

This survey study used data from the 2016-2018 Behavioral Risk Factor Surveillance System on 149 290 individuals residing in 17 states and the District of Columbia, representing the experiences of more than 61 million US adults.

Exposure

Private (individually purchased and employer-sponsored coverage) or public health insurance (Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage).

Main Outcomes and Measures

A pairwise multivariable analysis was performed, controlling for underlying health status of US adults covered by private and public health insurance plans, and responses to survey questions on access to care, costs of care, and reported satisfaction with care were compared. Estimates are weighted.

Results

A total of 149 290 individuals responded to the survey (mean [SD] age, 50.7 [0.2] years; 52.8% female). Among the respondents, most were covered by private insurance (95 396 [63.9%]), followed by Medicare (35 531 [23.8%]), Medicaid (13 286 [8.9%]), and VHA or military (5074 [3.4%]) coverage. Among those with private insurance, most (117 939 [79.0%]) had employer-sponsored coverage. Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64). Compared with individuals covered by Medicaid, those with employer-sponsored insurance were more likely to report having medical debt (OR, 2.06; 95% CI, 1.83-2.32) and were less likely to report difficulty seeing a physician because of costs (OR, 0.83; 95% CI, 0.73-0.95) and not taking medications because of costs (OR, 0.78; 95% CI, 0.66-0.92). No difference in satisfaction with care (OR, 0.96; 95% CI, 0.87-1.06) was found between individuals with employer-sponsored private health insurance and those with Medicaid coverage.

Conclusions and Relevance

In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.

Insurance Reimbursement in Plastic Surgery

SUMMARY

The ambiguity of medical finances, both to the patient and to the provider, has direct effects on the quality of care that is delivered to the patient. To encourage transparency in health care, physician reimbursement is a process that must be understood to ensure patient satisfaction, a physician's willingness to deliver care, and the success of health care facilities. Furthermore, physicians should be aware of the effects that legislative action, such as the Patient Protection and Affordable Care Act, has on their income. As a field that encompasses both cosmetic and reconstructive surgery, plastic surgeons must know this process intimately to ensure efficient services and appropriate reimbursement. In particular, plastic surgeons should be familiar with how the Affordable Care Act affects their income, practice, and the patient's access to care. As Medicare and Medicaid continue to increase health care access for many Americans, specialists such as plastic surgeons will need to reinforce the value of the specialty in the continuum of care. As the health care industry moves away from a fee-for-service system to one of value-based care, plastic surgeons need to be at the forefront of this transition to ensure that they are delivering quality care, and receiving appropriate reimbursement. The authors have provided data from the University of Michigan to demonstrate the reimbursement patterns seen in plastic surgery. This Special Topic article provides insight into the reimbursement process in the era of the Affordable Care Act and the various challenges that may be encountered within this field.

Cardiac Surgery Utilization Across Vulnerable Persons After Medicaid Expansion

BACKGROUND

Medicaid expansion (ME) under the Affordable Care Act has reduced the number of uninsured patients, although its preferential effects on vulnerable populations have been mixed. This study examined whether ME preferentially improved cardiac surgery use by insurance strata, race, and income level.

METHODS

Non-elderly adults (aged 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair were identified in the State Inpatient Databases for 3 expansion states (Kentucky, New Jersey, and Maryland) and 2 non-expansion states (North Carolina and Florida) from 2012 to the third quarter of 2015. We used adjusted Poisson interrupted time series to determine the impact of ME on cardiac surgery use for Medicaid or uninsured (MCD/UIS) patients, racial and ethnic minorities, and individuals from low-income areas.

RESULTS

In expansion states, use among non-White MCD/UIS patients had a positive trend after ME (2.3%/quarter; P = .156), whereas use for White MCD/UIS patients fell (-1.7%/quarter; P = .117). In contrast, use among non-White MCD/UIS in non-expansion states decreased by 4.4% (P < .001) which was a greater decline than among White MCD/UIS patients (-1.8%/quarter; P = .057). There was no substantial effect of ME on cardiac surgery use for MCD/UIS patients from low- versus high-income areas.

CONCLUSIONS

These findings demonstrate that the use of cardiac surgical procedures was generally unchanged after ME; however, nonsignificant trend differences suggest a narrowing gap between vulnerable and non-vulnerable groups in ME states. These preliminary findings help describe the association of insurance coverage as a driver of cardiac surgery use among vulnerable patients.

Medicaid for the Plastic and Reconstructive Surgeon

Medicaid is a complex federally and state funded health insurance program in the United States that insures an estimated 76 million individuals, approximately 20 percent of the U.S. population. Many physicians may not receive formal training or education to help understand the complexities of Medicaid. Plastic surgeons, residents, and advanced practice practitioners benefit from a basic understanding of Medicaid, eligibility requirements, reimbursement methods, and upcoming healthcare trends. Medicaid is implemented by states with certain federal guidelines. Eligibility varies from state to state (in many states it's linked to the federal poverty level), and is based on financial and nonfinancial criteria. The passage of the Affordable Care Act in 2010 permitted states to increase the federal poverty level eligibility cutoff to expand coverage for low-income adults. The aim of this review is to provide a brief history of Medicaid, explain the basics of eligibility and changes invoked by the Affordable Care Act, and describe how federal insurance programs relate to plastic surgery, both at academic institutions and in community practice environments.

Access to Elective Orthopaedic Surgery After the Affordable Care Act Medicaid Expansion: The New York State Experience

BACKGROUND

As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers.

METHODS

We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports.

RESULTS

Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both).

CONCLUSIONS

Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion

BACKGROUND

Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).

METHODS

Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014).

RESULTS

The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).

CONCLUSION

Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.

Impact of the Affordable Care Act on elective general surgery clinical practice

BACKGROUND

The Affordable Care Act (ACA) dramatically changed the healthcare system in the United States. This study aims to analyze the impact of the ACA on general surgery clinic visits and resultant procedures.

METHODS

A retrospective review was conducted on new patients who presented to the elective general surgery clinic at an academic medical center between Jan. 1, 2012 and Dec. 31, 2015. Based on the open enrollment start date of Jan.1, 2014 patients were divided into pre-ACA and post-ACA periods. Data on demographics, type of insurance, missed appointments, and elective surgical procedures performed were collected.

RESULTS

Medi-Cal insurance coverage increased post-ACA from 20.9% to 56.7%, p < 0.001; self-pay status went from 9.8% to 0%. There were 296 (35.4%) surgical procedures performed pre-ACA and 347 (37.1%) post-ACA (p = 0.445). Missed clinic visits decreased after implementation of the ACA, with 26.8% no-shows pre-ACA and 20.7% no-shows post-ACA (p = 0.003).

CONCLUSION

The ACA had a profound impact on the general surgery clinic with fewer uninsured patients, fewer no-shows and a modest increase in the number of procedures performed.

SUMMARY

In 2014 the Affordable Care Act mandate was implemented. This legislation impacted healthcare by significantly decreasing the number of uninsured patients and increasing overall volume in one general surgery clinic.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery

BACKGROUND

While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures.

METHODS

The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non-privately insured patients (Medicaid and uninsured patients) and privately insured patients.

RESULTS

Analysis of the number of non-privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11-1.19) vs -4.0% (IRR 0.96, 95% CI:0.94-0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0-1.1) vs -5.3% (IRR 0.95, 95% CI:0.93-0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states.

CONCLUSION

In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non-privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures.

Examining Healthcare Segregation Among Racial and Ethnic Minorities Receiving Spine Surgical Procedures in the State of Florida

STUDY DESIGN

This was a retrospective review of the Florida Inpatient Dataset (2011-2014).

OBJECTIVE

To examine healthcare segregation among African American and Hispanic patients treated with one of four common spine surgical procedures.

SUMMARY OF BACKGROUND DATA

Racial and ethnic minorities are known to be at increased risk of adverse events after spine surgery. Healthcare segregation has been proposed as a source for these disparities, but has not been systematically examined for patients undergoing spine surgery.

METHODS

African American, Hispanic, and White patients who underwent one of the four lumbar spine surgical procedures under study were included. Volume cut-offs were previously established for surgical providers and hospitals. Surgeons and hospitals were dichotomized based on these metrics as low- or high-volume providers. Multivariable logistic regression analysis was used to determine the likelihood of patients receiving surgery from a low volume provider, adjusting for sociodemographic and clinical characteristics.

RESULTS

African Americans were found to be at significantly increased odds of receiving surgery from a low-volume surgeon (P < 0.001) and were significantly more likely to receive surgery at a low-volume hospital (P < 0.007) for all procedures except decompression (P = 0.56). Like findings were encountered for Hispanic patients. Hispanic patients were 55% to three-times more likely to receive surgery from a low-volume surgeon depending on the procedure and 28% to 56% more likely to be treated at a low-volume hospital. African Americans were 34% to 82% more likely to receive surgery from a low-volume surgeon depending on the procedure and 10% to 17% more likely to be treated at a low-volume hospital.

CONCLUSION

The results of this work identify the phenomenon of racial and ethnic healthcare segregation among low-volume providers for lumbar spine procedures in the State of Florida. This may be a contributing factor to the increased risk of adverse events after spine surgery known to exist among minorities.

LEVEL OF EVIDENCE

3.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees

OBJECTIVE

The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees.

METHODS

We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization.

RESULTS

MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)].

CONCLUSIONS

MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND

Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.

STUDY DESIGN

From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.

RESULTS

The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.

CONCLUSIONS

Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.

The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among "carve-out" enrollees

Interrupted time series with and without controls was used to evaluate whether the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and its Interim Final Rule increased the probability of specialty behavioral health treatment and levels of utilization and expenditures among patients receiving treatment. Linked insurance claims, eligibility, plan and employer data from 2008 to 2013 were used to estimate segmented regression analyses, allowing for level and slope changes during the transition (2010) and post-MHPAEA (2011-2013) periods. The sample included 1,812,541 individuals ages 27-64 (49,968,367 person-months) in 10,010 Optum "carve-out" plans. Two-part regression models with Generalized Estimating Equations were used to estimate expenditures by payer and outpatient, intermediate and inpatient service use. We found little evidence that MHPAEA increased utilization significantly, but somewhat more robust evidence that costs shifted from patients to plans. Thus the primary impact of MHPAEA among carve-out enrollees may have been a reduction in patient financial burden.

Assessing In-Hospital Outcomes and Resource Utilization After Primary Total Joint Arthroplasty Among Underweight Patients

BACKGROUND

Poor nutritional status is a preventable condition frequently associated with low body mass index (BMI). The purpose of this study is to comparatively analyze low (≤19 kg/m(2)) and normal (19-24.9 kg/m(2)) BMI cohorts, examining if a correlation between BMI, postoperative outcomes, and resource utilization exists.

METHODS

Discharge data from the 2006-2012 National Inpatient Sample were used for this study. A total of 3550 total hip arthroplasty (THA) and 1315 total knee arthroplasty (TKA) patient samples were divided into 2 cohorts, underweight (≤19 kg/m(2)) and normal BMI (19-24.9 kg/m(2)). Using the Elixhauser Comorbidity Index, all cohorts were matched for 27 comorbidities. In-hospital postoperative outcomes and resource utilization among the cohorts was then comparatively analyzed. Multivariate analyses and chi-squared tests were generated using SAS software. Significance was assigned at P < .05.

RESULTS

Underweight patients undergoing THA were at higher risk of developing postoperative anemia and sustaining cardiac complications. In addition, underweight patients had a decreased risk of developing postoperative infection. Resource utilization in terms of length of stay and hospital charge were all higher in the underweight THA cohort. Similarly, in the underweight TKA cohort, a greater risk for the development of hematoma/seroma and postoperative anemia was observed. Underweight TKA patients incurred higher hospital charge and were more likely to be discharged to skilled nursing facilities.

CONCLUSION

Our results indicate that low-BMI patients were more likely to have postoperative complications and greater resource utilization. This serves a purpose in allowing orthopedic surgeons to better predict patient outcomes and improve treatment pathways designed toward helping various patient demographics.

The influence of race and hospital environment on the care of patients with cervical spine fractures

BACKGROUND

The influence of non-white race on outcomes following orthopedic injury has been described in the past. The impact of such factors on hospital processes and quality of care after spinal trauma is less well understood.

STUDY DESIGN

A cohort control study using the Massachusetts Statewide Inpatient Dataset (2003-2010) was used as the study design.

PURPOSE

This study aimed to determine whether (1) hospital processes and quality of care associated with the treatment of cervical spine fractures was significantly altered by non-white race and (2) whether findings were different among those treated at academic medical centers (AMCs).

SAMPLE

The study comprised 10,841 patients.

OUTCOMES

Surgical rate, postoperative morbidity, mortality, and length of stay (LOS) were the outcome measures.

METHODS

Baseline differences between cohorts were evaluated using chi-square or Wilcoxon rank sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Subset analyses were performed to evaluate whether findings were different for individuals treated at AMCs.

RESULTS

The rate of surgical intervention was not significantly different between non-whites and whites (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.82-1.04). LOS (regression coefficient [RC] 0.18, 95% CI 0.13-0.23), mortality (OR 1.49, 95% CI 1.20-1.85), and complications (OR 1.17, 95% CI 1.02-1.33) were significantly increased among non-white patients. These findings were largely preserved among those treated at AMCs.

CONCLUSIONS

Our results reinforce the fact that efforts at universal access to care may be insufficient to reduce differences in care among minority patients following cervical trauma. Future mixed-methods research is necessary to more effectively evaluate the etiologies behind health-care disparities associated with race in different health-care environments.

LEVEL OF EVIDENCE

The level of evidence is Level III, prognostic study.

Trauma transfers to a rural level 1 center: a retrospective cohort study

BACKGROUND

The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.

METHODS

We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.

RESULTS

5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).

CONCLUSIONS

These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.

Does Health Reform Change Femoral Neck Fracture Care? A Natural Experiment in the State of Massachusetts

OBJECTIVES

To determine whether hospital processes and hospital quality associated with the care of femoral neck fractures were significantly altered by the implementation of healthcare reform in Massachusetts.

DESIGN

Pre-post retrospective study.

SETTING

Massachusetts Statewide Inpatient Dataset (SID).

PATIENTS/PARTICIPANTS

Patients treated for femoral neck fracture (n = 23,485) in the periods prehealth (2003-06) and posthealth reform (2008-10).

INTERVENTION

Differences in hospital processes for fracture care and quality measures were assessed for the periods before and after health reform.

OUTCOME MEASUREMENTS

Differences in hospital processes for fracture care (type of surgical intervention, length of stay, and discharge disposition) and quality metrics [mortality, complications, re-operation, and failure to rescue (FTR)] in the periods before and after health reform were assessed using regression techniques to adjust for differences in case mix and the type of surgical intervention.

RESULTS

There were no significant differences in the type of surgical intervention performed prereform and postreform (P = 0.27). After adjustment for case mix and surgical intervention, length of stay was significantly reduced {regression coefficient -0.07 [95% confidence interval (CI), -0.09 to -0.06]} as were the odds of FTR [odds ratio 0.73 (95% CI, 0.59-0.92)]. Discharges to skilled nursing facilities significantly increased in the postreform period [relative risk ratio 1.15 (95% CI, 1.03-1.30)]. Findings associated with FTR were driven by changes in the detection of surveillance sensitive complications.

CONCLUSIONS

Health reform in Massachusetts led to no clinically meaningful differences in hospital processes for femoral neck fracture care. Although some differences in quality measures were noted, these cannot necessarily be attributed to health care reform.

Small-Area Estimation of Spatial Access to Care and Its Implications for Policy

Local or small-area estimates to capture emerging trends across large geographic regions are critical in identifying and addressing community-level health interventions. However, they are often unavailable due to lack of analytic capabilities in compiling and integrating extensive datasets and complementing them with the knowledge about variations in state-level health policies. This study introduces a modeling approach for small-area estimation of spatial access to pediatric primary care that is data "rich" and mathematically rigorous, integrating data and health policy in a systematic way. We illustrate the sensitivity of the model to policy decision making across large geographic regions by performing a systematic comparison of the estimates at the census tract and county levels for Georgia and California. Our results show the proposed approach is able to overcome limitations of other existing models by capturing patient and provider preferences and by incorporating possible changes in health policies. The primary finding is systematic underestimation of spatial access, and inaccurate estimates of disparities across population and across geography at the county level with respect to those at the census tract level with implications on where to focus and which type of interventions to consider.

Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction

BACKGROUND

Breast reconstruction after mastectomy has been shown to provide substantial clinical and psychosocial benefits for many patients; however, disparities in the use of immediate postmastectomy breast reconstruction persist. Using the unique dataset from the New York State Inpatient Database, the following developments were studied: (1) trends in immediate postmastectomy breast reconstruction between 1998 and 2006 among white, African American, and Hispanic women; (2) factors associated with its use; and (3) changes in racial/ethnic variation in immediate postmastectomy breast reconstruction before and after implementation of the New York State Medicaid expansion in 2001.

METHODS

A step-in multivariable logistic regression model was used to assess the effect of race/ethnicity, age, mastectomy type, number of comorbidities, socioeconomic status, and insurance on the probability of undergoing immediate postmastectomy breast reconstruction. Then, adjusted immediate postmastectomy breast reconstruction rates for before and after Medicaid expansion were predicted, stratified by race/ethnicity.

RESULTS

The probability of undergoing immediate postmastectomy breast reconstruction increased (p < 0.001); however, even with Medicaid expansion occurring during the 8 years studied, gaps in use between white and African American women and between white and Hispanic women increased by 6 percent (95% CI, 0.07 to 0.05) and 5 percent (95% CI, 0.07 to 0.04), respectively. Being younger, having greater income and education, and having private health insurance are associated with a greater probability of immediate postmastectomy breast reconstruction.

CONCLUSION

These findings indicate that expanding safety-net policies such as Medicaid without providing support such as consultation or health literacy education might not be effective in reducing disparities in health care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.